Nursing Process 1 Test Questions

Correct Answer: D

Rationale: Step-by-step rationale: 1. A balanced and varied diet provides essential nutrients for immune function. 2. Including a wide range of foods ensures intake of vitamins, minerals, and antioxidants crucial for immune health. 3. Avoiding extremes like excessive immune-enhancing formulas or eliminating polyunsaturated fatty acids maintains balance. 4. Essential fatty acids and omega-3 fatty acids are beneficial but should be part of a well-rounded diet. 5. For clients with immune-mediated disorders, individualized dietary advice may be necessary. Summary: - A: Immune-enhancing formulas may not be necessary and could disrupt balance. - B: Avoiding all polyunsaturated fatty acids is not advisable as some are essential for health. - C: Increasing essential fatty acids is beneficial but should be part of a balanced diet.

Correct Answer: D

Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery. Explanation for other choices: A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed. B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain. C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.

Correct Answer: C

Rationale: The correct answer is C: Increased comfort. Radiation therapy for lung cancer aims to alleviate symptoms, reduce pain, and improve quality of life. It is not typically used as a curative treatment like surgery or chemotherapy (A). It does not prevent the need for oxygen (B), as lung cancer can still affect lung function. While radiation therapy may help control the growth of cancer cells, it is not always effective in preventing cancer spread (D). Therefore, the most appropriate expectation of radiation therapy for lung cancer is increased comfort for the patient.

Correct Answer: B

Rationale: The correct answer is B: Isolated systolic hypertension. This is because in isolated systolic hypertension, the systolic blood pressure is elevated while the diastolic blood pressure remains normal. This condition is common in older adults and is often related to aging and stiffening of the arteries. Primary hypertension (A) typically involves both elevated systolic and diastolic pressures. Secondary hypertension (C) is caused by an underlying condition. Hypertensive emergency (D) is characterized by severe elevations in both systolic and diastolic pressures with acute target organ damage.

Correct Answer: A

Rationale: The correct answer is A because it includes essential nursing interventions for a patient with head injuries like J.E. Skin care and position changes every 2 hours help prevent pressure ulcers. Maintaining alignment of extremities prevents contractures. Respiratory exercises aid in lung function. Option B lacks the crucial aspect of maintaining extremity alignment. Option C includes teaching the use of an overhead trapeze, which may not be appropriate for J.E. Option D lacks the instruction to maintain extremity alignment, which is crucial for preventing contractures in patients with head injuries.